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14.
A 19-year-old man is brought to the emergency department by his friend 15 minutes after he sustained a gunshot wound to his face immediately below his right lower lip. On arrival, the patient is in pain but is able to answer questions. Medical history is unremarkable and the patient takes no medications. He is allergic to penicillin. Vital signs are temperature 37.0°C (98.6°F), pulse 80/min, respirations 16/min, and blood pressure 120/80 mm Hg. The patient's face and right lower lip appear as shown in the photograph. The remainder of the physical examination discloses no abnormalities.
http://i42.photobucket.com/albums/e338/G...30c244.png
Which of the following is the most appropriate antibiotic therapy?
A) Amoxicillin
B) Ciprofloxacin
C) Clindamycin
D) Linezolid
E) Sulfamethoxazole
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Ans: C
nbme cert.
In this case because of the proximity of the lesion to the mouth we cover anaerobes, Clindamycin is a good choice.
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15.
A 32-year-old man with schizophrenia is brought to the emergency department by ambulance from a supervised living facility because he has had altered mental status during the past 3 hours. The patient's caregiver at the facility, who accompanies the patient, says, "He's usually fairly quiet, but today he is hardly responding to anything I ask him." The patient also had an episode of urinary incontinence 1 hour ago. He has a history of type 2 diabetes mellitus and chronic productive cough. Medications include glyburide and haloperidol; haloperidol was recently switched from oral (5 mg three times daily) to intramuscular (150 mg monthly). The patient smokes two packs of cigarettes daily. He has a history of intermittent binge alcohol abuse and intravenous illicit drug use. His caregiver says that, to her knowledge, he has been sober for the past month and is no longer using illicit drugs. On arrival, the patient does not respond verbally to questions but withdraws from painful stimuli. Vital signs are temperature 39.9°C (103.8°F), pulse 122/min, respirations 18/min, and blood pressure 148/94 mm Hg. He is diaphoretic and tremulous. Auscultation of the chest discloses coarse expiratory rhonchi. Cardiac examination discloses rapid rate but no other abnormalities. The abdomen is firm and bowel sounds are absent. Extremities are rigid. Which of the following is the most likely cause of this patient's condition?
A) Alcohol withdrawal syndrome
B) Diabetic ketoacidosis
C) Neuroleptic malignant syndrome
D) Sepsis
E) Stimulant drug intoxication
16.
A 10-month-old infant is brought to the emergency department because of a 4-day history of a barking cough. The mother noticed that during the past 2 days, the infant has been having difficulty breathing and often awakens because of coughing. The mother reports that two similar episodes have occurred during the past 4 months. On physical examination the child is alert. Temperature is 37.6°C (99.6°F) and respirations are 60/min. Bilateral wheezes are heard on auscultation and intercostal retractions are evident. A chest x-ray of this infant is most likely to show which of the following findings?
A) Bilateral hyperinflation with flattened diaphragms
B) Lobar infiltrates
C) Pleural effusion with tracheal deviation
D) Segmental emphysema
E) Unilateral interstitial infiltrates
17.
A 13-year-old girl is brought to the emergency department by her parents because of a 2-day history of worsening, severe pelvic pain and abdominal bloating. The patient reports a 3-month history of less severe, cyclic, crampy lower pelvic pain that, prior to this episode, had been controlled with acetaminophen as needed. Menarche has not occurred. The patient is 160 cm (5 ft 3 in) tall and weighs 50 kg (110 lb). Vital signs are normal. Sexual maturity rating (SMR) is 4 for breast and axillary hair development. Physical examination discloses a mildly distended abdomen with a mass palpated just above the suprapubic bone. External genitalia appear normal; speculum examination is prevented by a thin, bluish-tinged, bulging membrane obstructing the path just beyond the introitus. Which of the following is the most likely diagnosis?
A) Congenital absence of the uterus
B) Endometriosis
C) Hematocolpos
D) Sarcoma botryoides
18.
An 18-year-old white man comes to the emergency department because of a 24-hour history of throat pain when he swallows. The pain began immediately after awakening. He describes the pain as dull, severe, boring, and localizing to the midchest area. He has not vomited or had any respiratory symptoms. His only medication is oral tetracycline for facial acne. Vital signs are temperature 36.5°C (97.7°F), pulse 82/min, respirations 18/min, and blood pressure 126/74 mm Hg. The patient is not in acute distress, but he appears uncomfortable when he swallows. Physical examination shows moderate facial acne and no other abnormalities. Which of the following is the most likely diagnosis?
A) Diffuse esophageal spasm
B) Gastritis secondary to Helicobacter pylori infection
C) Globus hystericus
D) Pill esophagitis
E) Pneumomediastinum
19.
An 85-year-old woman is brought to the emergency department by her daughter because of a 2-month history of intermittent episodes of dizziness when rising from a supine position. The daughter is visiting from another state and has not seen her mother during the past 6 months. A neighbor checks on the patient weekly and brings her groceries. The patient says she has always been generally healthy and has not received care from a physician during the past 20 years. She takes no medications. Today she appears frail and pale, but she is alert and oriented to person, place, and time. She is 165 cm (5 ft 5 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2. Vital signs are normal. Physical examination shows no abnormalities. Results of laboratory studies are shown:
Blood
Hemoglobin 11 g/dL
WBC 24,000/mm3
Platelet count 280,000/mm3
Peripheral blood smear is obtained and shown. Bone marrow biopsy confirms the diagnosis. After you explain the diagnosis to the daughter, the daughter says, "I want you to do the most aggressive treatment possible." Which of the following is the most appropriate response?
A) Chemotherapy should be started now
B) Her mother should be referred for hospice care
C) Her mother will not require treatment unless her condition worsens
D) An MRI of the brain should be obtained before any decisions regarding treatment are made
E) Splenectomy should be done immediately
20.
A 14-year-old boy is brought to the emergency department by paramedics after he fell from a tree. Initial evaluation discloses an open, displaced fracture of the femur. The patient is alert and vital signs are normal. His parents are not with him and are not available by phone. The most appropriate action is to proceed with the physical examination and do which of the following?
A) Delay any intervention until either the parents are located or the appropriate state agency is contacted
B) Delay any intervention until the parents can be located for consent
C) Proceed with all necessary emergency treatments, including surgical repair, while continuing attempts to contact his parents
D) Proceed with nonoperative interventions, but delay surgical repair until his parents can be located for consent
E) Proceed with nonoperative interventions while the hospital attorney arranges an emergency court hearing
21.
A 26-year-old woman comes to the emergency department because of a 36-hour history of upper abdominal pain, nausea, and vomiting. During this time, she has been unable to retain any food or liquids, including water, and she has vomited approximately four times. The patient says she is a "dietary fanatic" and that her usual diet consists only of fruits and vegetables. She says that 3 days ago she began eating a large number of persimmon pits, orange peels, and watermelon seeds because she read that these products are especially nutritious. She notes that her vomitus contained varying amounts of these fruit particles. She does not take any medications. Vital signs on arrival in the emergency department are temperature 36.9°C (98.4°F), pulse 100/min, respirations 16/min, and blood pressure 90/60 mm Hg. Measurement of serum electrolyte concentrations is most likely to show which of the following?
Na+ K+ HCO3− Cl− pH
(mEq/L) (mEq/L) (mEq/L) (mEq/L) (mEq/L)
A) 126 4.2 36 110 7.54
B) 128 2.9 35 80 7.56
C) 136 4.9 18 98 7.24
D) 138 2.9 25 106 7.38
E) 148 3.8 24 115 7.41
22.
An 84-year-old woman comes to the emergency department because of a 3-hour history of pain in her right leg and foot. She rates the pain as a 10 on a 10-point scale. The patient reports a 1-year history of an "aching pain" that is worse with walking and generally subsides with rest. She has not had fever, chills, or a history of trauma. She has a 20-year history of type 2 diabetes mellitus complicated by nephropathy, neuropathy, and retinopathy. Medical history is also remarkable for hypertension, ischemic heart disease, transient ischemic attacks, and osteoarthritis of the hips, knees, and spine. Current medications include lisinopril, furosemide, transdermal nitroglycerin, metoprolol, lovastatin, losartan, acetaminophen, glipizide, and 81-mg aspirin. She has no medication allergies. Vital signs are temperature 36.9°C (98.4°F), pulse 92/min, respirations 14/min, and blood pressure 166/90 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. During the physical examination, particular attention should be given to which of the following?
A) Gait
B) Hip rotation
C) Muscle mass
D) Peripheral pulses
E) Skin color
23.
A woman who appears to be in her mid-30s is brought to the emergency department by police 20 minutes after she was found acting erratically and pacing back and forth at a street corner. On arrival, the patient is initially calm but refuses to give her name. She asks to leave but is told by the police that she is on a legal hold for psychiatric reasons. The patient resists physical examination. She then refuses to provide a urine sample but urinates on the floor and says, "Sample this!" She yells at the camera in the seclusion room, threatening to "get the people who turned me in." She then begins to pound on the door and throws herself against it. Which of the following is most indicative of the need for forcible intramuscular injection of an antipsychotic medication?
A) Attempts to leave
B) Making verbal threats
C) Status as a legal hold patient
D) Throwing herself at the door
E) Unwillingness to identify herself
F) Urinating on the floor
24.
A 5-month-old boy is brought to the emergency department by his mother because he has not moved his right leg for the past 8 hours, and he cries when he is picked up. He is currently taking amoxicillin for treatment of an ear infection. He has been otherwise healthy. He drinks 30 oz of cow milk formula daily and eats some cereal, fruits, and vegetables. Vaccinations are up-to-date. Development has been normal; he rolls over, smiles responsively and spontaneously, and transfers. Family history is unremarkable. He has a 4-year-old sister who is healthy. He lives with his mother and sister, and his grandmother cares for him during the day while his mother works in a convenience store. The mother had a boyfriend living in her apartment but told him to leave earlier in the week because of a disagreement. The patient appears healthy. He currently is 67 cm (26 in; 75th percentile) in length, weighs 8.1 kg (17 lb 10 oz; 50th percentile), and head circumference is 43 cm (17 in; 50th percentile). Vital signs are temperature 36.4°C (97.5°F), pulse 120/min, and respirations 20/min. He cries when moved and during examination. Anterior fontanel is soft. Tympanic membranes are mildly erythematous with diminished landmarks. The remainder of the examination discloses no abnormalities. X-ray of the right leg is shown.
Which of the following is the most appropriate next step in diagnosis?
A) Determination of erythrocyte sedimentation rate
B) Determination of serum alkaline phosphatase activity
C) Determination of serum calcium and phosphorus concentrations
D) Radionuclide bone scan
E) Skeletal survey
25.
A mother and her six children are referred to the emergency department by the county health agency because they have been exposed to elemental mercury. The mother, a single parent, discovered a jar of mercury in her 12-year-old son's bedroom. Her son said he found the material about 1 month ago in an abandoned laboratory building in their neighborhood. He shares his room with his 9-year-old and 7-year-old brothers, who also have been playing with the mercury. Twin girls, age 6 years, and one other sister, age 4 years, sleep in another room and apparently have not been in contact with the substance. The mother is anxious and upset about the situation, but she reports no new physical symptoms or signs in her children. The children appear to be in good health. They are frightened and cling to their mother. Physical examinations of all seven patients are normal. The family is placed in temporary housing. In counseling the mother you would inform her that the most frequent early symptoms and signs of subacute or chronic mercury toxicity involve which of the following?
A) Bone marrow
B) Central nervous system
C) Endocrine system
D) Liver
E) Respiratory system
26.
A 67-year-old man is brought to the emergency department by ambulance because of two episodes of chest pressure and mild shortness of breath that occurred at rest. The first episode occurred 1½ hours ago and subsided spontaneously 20 minutes later; the second episode began 30 minutes ago and has persisted. He has not had nausea or diaphoresis. Paramedics placed an intravenous line and initiated 2 L/min oxygen via nasal cannula and aspirin therapy. On arrival in the emergency department the patient says his chest pain is slightly improved and now rates it as a 5 on a 10-point scale. Medical history is remarkable for type 2 diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. Routine medications include glyburide, amlodipine, an ipratropium-albuterol inhaler, and 81-mg aspirin. The patient appears moderately obese. Vital signs are temperature 37.2°C (99.0°F), pulse 88/min, respirations 18/min, and blood pressure 165/95 mm Hg. Pulse oximetry on 2 L oxygen via nasal cannula shows an oxygen saturation of 98%. Physical examination discloses no jugular venous distention or bruits. Auscultation of the lungs discloses decreased breath sounds with mild, diffuse end-expiratory wheezes. Cardiac examination discloses a regular rate and rhythm with no audible murmurs, rubs, or gallops. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate immediate next step?
A) Inhaled albuterol-ipratropium therapy
B) Intravenous metoprolol therapy
C) Intravenous nitroglycerin therapy
D) 12-Lead ECG
E) Portable chest x-ray
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15C..rigidity,fever, vitals unstable
16A croup ??
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15 is def C
16 its croup I put D and got it wrong
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15.
A 32-year-old man with schizophrenia is brought to the emergency department by ambulance from a supervised living facility because he has had altered mental status during the past 3 hours. The patient's caregiver at the facility, who accompanies the patient, says, "He's usually fairly quiet, but today he is hardly responding to anything I ask him." The patient also had an episode of urinary incontinence 1 hour ago. He has a history of type 2 diabetes mellitus and chronic productive cough. Medications include glyburide and haloperidol; haloperidol was recently switched from oral (5 mg three times daily) to intramuscular (150 mg monthly). The patient smokes two packs of cigarettes daily. He has a history of intermittent binge alcohol abuse and intravenous illicit drug use. His caregiver says that, to her knowledge, he has been sober for the past month and is no longer using illicit drugs. On arrival, the patient does not respond verbally to questions but withdraws from painful stimuli. Vital signs are temperature 39.9°C (103.8°F), pulse 122/min, respirations 18/min, and blood pressure 148/94 mm Hg. He is diaphoretic and tremulous. Auscultation of the chest discloses coarse expiratory rhonchi. Cardiac examination discloses rapid rate but no other abnormalities. The abdomen is firm and bowel sounds are absent. Extremities are rigid. Which of the following is the most likely cause of this patient's condition?
A) Alcohol withdrawal syndrome
B) Diabetic ketoacidosis
C) Neuroleptic malignant syndrome
D) Sepsis
E) Stimulant drug intoxication
Ans:C
nbme cert.
:::::::::::::::::::::::::::::::::::::::::
Neuroleptic malignant syndrome:
Onset: Not time limited
Symptoms: Muscular rigidity, fever, autonomic changes, agitation, and obtundation.
CPK and K can be elevated.
Treatment: Dantrolene or bromocriptine
Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 516)
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Hey!
Thanks for the explanations, now ur talking guys! 
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16.
A 10-month-old infant is brought to the emergency department because of a 4-day history of a barking cough. The mother noticed that during the past 2 days, the infant has been having difficulty breathing and often awakens because of coughing. The mother reports that two similar episodes have occurred during the past 4 months. On physical examination the child is alert. Temperature is 37.6°C (99.6°F) and respirations are 60/min. Bilateral wheezes are heard on auscultation and intercostal retractions are evident. A chest x-ray of this infant is most likely to show which of the following findings?
A) Bilateral hyperinflation with flattened diaphragms
B) Lobar infiltrates
C) Pleural effusion with tracheal deviation
D) Segmental emphysema
E) Unilateral interstitial infiltrates
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15) C NBME Cert
16) I GOT IT WRONG PUT D -----ANSWER IS A
17) D WRONG BY NBME----- NO idea about the answer
18) C WRONG BY NBME ---- is it pills?? saying he has acne ???
19) I FORGOT TO WRITE MY ANSWER
20-C NBME CERT
21) B NBME CERT
22) D NBME CERT
23) D NBME CERT
24) E NBME CERT
25) B NBME CERT
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17) D WRONG BY NBME----- NO idea about the answer
18) C WRONG BY NBME ---- is it pills?? saying he has acne ???
19) I FORGOT TO WRITE MY ANSWER
20- OF you an minor always proceed with emergency actions
21) - Vomiting pt MEtabolic alkalosis
22) arterial embolism
23) PCP violent crazy women haha
24) Abuse 
25) Mercury cause memory issues and CNS problems
26) I got it wrong thinks D>???
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